This article is written and submitted by the Foundation for Healthy Communities, an affiliate of the New Hampshire Hospital Association, as part of its support of the SPARC Grant Initiative.
In 2022, Littleton Regional Healthcare (LRH) initiated a Mobile Integrated Healthcare (MIH) program aimed at increasing access to health care in rural northern New Hampshire. With funding from the Strategic Population Health Activities for Rural Communities (SPARC) grant from the Department of Health and Human Services, this innovative program demonstrates a promising model to improve the care of patients who have difficulty accessing needed medical care.
Living in rural New Hampshire can present its share of challenges when seeking health care. Fewer primary care providers, a scarcity of transportation options, and social isolation can make it difficult for those living in northern New Hampshire to effectively manage their health. The onset of the COVID-19 pandemic in 2020 exacerbated these challenges, further limiting access to necessary medical care. Ed Daniels, Coordinator of Emergency Medical Services (EMS) and Mobile Integrated Healthcare (MIH) at Littleton Regional Healthcare (LRH) in northern New Hampshire (NH), notes, ” Once COVID-19 hit, we found that many in our area were experiencing issues accessing needed health care. People were opting to stay home, not wanting to go out as much as they did prior to COVID. At this same time, we saw a rise in non-emergent 911 calls.”
In response, LRH started the MIH program, designed to address health care access issues by collaborating with local EMS providers to bring health care into the home. While the program took a year to gain traction, the team at LRH quickly experienced initial successes. One patient who was isolated at home had their first-ever visit with a primary care provider (PCP) using telehealth technology. The patient had not met their PCP previously but, thanks to the MIH program, they were able to connect with their provider and receive the care they needed. This encounter had a significant impact for the patient and highlighted the importance of bringing care into the patient’s home.
I got to stay in my home. You see, I live alone. I got my blood pressure regulated. I got to see Dr. Larson, which was a big help and eased my mind.
~Emily Heathe
Littleton Regional Healthcare MIH patient
Initially, the LRH MIH program was developed to address health care access challenges for patients with diabetes by providing care and support in the home. As the MIH program progressed, however, EMS providers recognized there was a need for MIH beyond diabetes management. Home-based care could be used for patients requiring assistance with mobility, medication management, post-surgery follow-ups, social needs, and chronic condition management. Expanding MIH services could support individuals who did not qualify for traditional home health services, thereby addressing a broader set of gaps in health care access. For instance, several referrals to the program were for patients who had been discharged from the hospital. During these visits, MIH providers reviewed discharge instructions and made sure patients understood them with fewer time constraints. Providers could also make arrangements for equipment to support mobility, such as a walker, support bars, or a shower stool, and make sure patients had access to their prescribed medications and understood how to take them.
A key aspect of LRH’s MIH program is its holistic approach to patient care. EMS providers not only sought to address medical needs but also identify and alleviate social needs impacting health, such as food insecurity, transportation, and social isolation. Addressing these underlying factors removed barriers and empowered patients to manage their health more effectively. “We identified early on that attending to these other issues supported the patient and helped them better manage their condition. When you have so many issues going on it can be overwhelming and affect your ability to manage your health,” said Daniels. “People are more than their condition.”
Understanding and responding to patient needs during the MIH visits sparked partnerships within the community. The program proved instrumental for building and strengthening partnerships between EMS, primary care providers, home health agencies, and other community stakeholders, leading to a more integrated and coordinated approach to health care delivery. “Relationships with EMS and local Home Health & Hospice agencies have grown with the creation of MIH in our area. Both services are becoming more knowledgeable about how the other works and, more importantly, how we can work together to provide more services in the home to patients in need,” says Daniels, “Partners are now more open to connecting with each other- even those who are not part of the MIH program. Everyone is more educated about available services and ways of working together as a result of this program.”
Giving Patients Confidence
My experience with MIH has been a very positive experience. The first patient interaction through MIH was for an elderly woman that had a leg amputated due to Diabetes. Her primary caregiver is her husband who is also a Diabetic. In the past we have had many 911 calls to their home. Their situation was quite overwhelming to them. Our visits provided a direct line to their physician, and it also made her provider aware of services that they may need. With MIH help, the calls to their home have stopped and they are managing their situation much better. Our help gave them confidence to get through a difficult time. I gained confidence in my EMS abilities by having frequent visits. As a rural community, folks can feel so alone, and it was so reassuring to them that we were checking on them.
~ Beth Hubbard, EMR, Lisbon EMS
As important as the basic medical evaluations we received were, the social/emotional connection provided was equally as important. Connecting with providers in our community, who were also our neighbors, at times that fit our daily schedule made the MIH visits welcome and easy.
~Bev and Bo Presby,
Littleton Regional Healthcare MIH patients
On its path to success, the MIH program overcame a few challenges. At first, health care providers reported feeling overwhelmed with adding another process into their busy workflow that would facilitate referrals to MIH. But care coordinators quickly stepped up and became an important asset, working with health care providers to identify and refer patients into the program. “They serve as the backbone of referrals,” says Daniels.
However, when staff turnover resulted in a decrease in referrals, Daniels and David Hirsch, MD, Medical Director of Emergency Medical Services (EMS) and Mobile Integrated Healthcare at LRH, identified an additional pathway to facilitate referrals into the program. Often, an EMS provider on a 911 call identifies a patient who could benefit from MIH. Seeing this as an opportunity, Dr. Hirsch implemented a standing order that allowed any EMS provider in the LRH service area to make a referral to one of the EMS agencies providing MIH in the area. The referral allowed the agency to contact the patient for a one-time in-home needs assessment. “The goal of this MIH encounter would be to identify any needs the patient may have and connect them to the necessary resources. This may include a referral to home health, feedback to the primary care provider, or connections with other community services. We have found this ‘resource mapping’ to be a huge advantage to the EMS agencies to ensure the proper assistance is provided to the patient.”
EMS providers are now observing a decrease in the number of non-transport 911 calls from some of their more frequent callers. “One patient I worked with… significantly decreased and then stopped his use of 911 services once we began a routine of MIH visits,” remarked Cathy Bisson, EMR, Lisbon EMS. “He felt connected and supported and often expressed how grateful he was for our visits. Eventually, we were able to decrease our MIH visits and then stop them completely.”
Daniels and Hirsch are now exploring alternative funding sources beyond grant programs to sustain the program for the long term. The SPARC funding enabled LRH to build the MIH program and bolster the budgets of community partners to pay for their MIH services. While EMS providers typically need to transport a patient in order to get reimbursement for their services, MIH is all about providing care and support in the home. “Searching and writing proposals for funding is new to us as EMS providers,” Daniels remarked, “But we are working hard to find additional sources.”
Mobile Integrated Health programs like the one implemented by LRH are instrumental in addressing health care access challenges in rural communities. Through innovative approaches and collaborative partnerships, these programs can significantly improve patient outcomes and enhance the overall quality of health care delivery.
RECOMMENDATIONS:
- Diversify program focus: Don’t get fixated on one specific program or population. Instead, focus on understanding the diverse needs of the community and tailor interventions accordingly. By addressing a range of health care challenges, programs can better serve the entire community.
- Engage EMS providers: EMS providers may not initially be familiar with or may be hesitant to engage in new programs like MIH. It’s crucial to actively engage them and discuss the benefits and important role they play in such initiatives. Frame MIH as “fire prevention for EMS,” emphasizing its proactive nature in preventing unnecessary 911 calls and improving patient outcomes.
- Seek sustainable funding: Successful MIH programs often require sustainable funding sources beyond initial grants. Explore partnerships with other health care organizations to leverage resources to support MIH initiatives. Additionally, consider innovative reimbursement models to ensure the longevity of the program.
- Build strong partnerships: Collaborating with local agencies, health care providers, and community stakeholders is key to the success of MIH programs. Foster strong partnerships to leverage resources, share expertise, and coordinate care effectively. By working together, stakeholders can maximize the impact of MIH initiatives and better meet the needs of the community.
This project was supported by the Centers for Disease Control (CDC) and Prevention’s OT21-2103 Initiative to Address COVID-19 Health Disparities Grant through cooperative agreement NH75OT000031 as part of an award totaling $24,568,469 to the New Hampshire Department of Health and Human Services, Division of Public Health Services. The contents of this interview are solely the responsibility of the authors and do not represent the official views of the Centers for Disease Control and Prevention
